Anurag Goel ST5, Gastroenterology. Definition: presence of free - - PowerPoint PPT Presentation

Anurag Goel ST5, Gastroenterology.

 Definition:

presence of free fluid in the peritoneal cavity

Cause Frequ quency ncy Cirrhosis 81% Cancer 10% Heart Failure 3% Tuberculosis 2% Dialysis 1% Pancreatic Disease 1% Other 2%

Caus uses es of

• f Asc

scites ites

Non-peritoneal causes Examples

Intrahepatic portal hypertension Cirrhosis Fulminant hepatic failure Veno-occlusive disease Extrahepatic portal hypertension Hepatic vein obstruction (ie, Budd-Chiari syndrome) Congestive heart failure Hypoalbuminemia Nephrotic syndrome Protein-losing enteropathy Malnutrition Miscellaneous disorders Myxedema Ovarian tumors Pancreatic & Biliary ascites Chylous Secondary to malignancy, trauma

Peritoneal Causes Examples

Malignant ascites Primary peritoneal mesothelioma Secondary peritoneal carcinomatosis Granulomatous peritonitis Tuberculous peritonitis Fungal and parasitic infections Sarcoidosis Foreign bodies (cotton ,starch, barium) Vasculitis Systemic lupus erythematosus Henoch-Schönlein purpura Miscellaneous disorders Eosinophilic gastroenteritis Whipple disease Endometriosis

Catego gory ry

Infectious diseases Amebiasis, Ascariasis, Brucellosis, Chlamydia peritonitis, Complications related to HIV infection, Pelvic inflammatory disease, Pseudomembranous colitis, Salmonellosis, Whipple's disease Hematologic Amyloidosis, Castleman's syndrome, Extramedullary hematopoiesis, Hemophagocytic syndrome, Histiocytosis X, Leukemia, Lymphoma, Mastocytosis, Multiple myeloma Miscellaneous Abdominal pregnancy, Crohn's disease, Endometriosis, Gaucher's disease, Lymphangioleiomyomatosis, Myxedema, Nephrotic syndrome, lymphatic tear or ureteral injury. Ovarian hyperstimulation

 Ultrasound with Dopplers

• Easily confirms ascites
• May see nodularity of cirrhosis
• Evaluate patency of vasculature
• No radiation, contrast

 CT / MRI

• Evaluation for malignancy

 Grade 1

• Mild, only detectable by U/S

 Grade 2

• Moderate, symmetrical distension

 Grade 3

• Gross or large with marked distension

 Large typically means painful/uncomfortable

 Refractory Ascites (5-10%)

• Can not be mobilized or early recurrence

refractory to medical management

NEJM 350:1646-54 Hepatology 2003; 38: 258-266

 15cm lateral and 2 cms below umbilicus  Avoid enlarged spleen and liver  Avoid sp and inf epigastric arteries  No data to support use of FFP  Most clinicians would give pooled platelets

if <40

 Complication:

• Haematoma<1%
• Bowel perforation/haemoperitoneum <0.1%

 10-20ml of fluid in a syringe with

blue/green needle

Go 2cm below the umbilicus in the midline or 3 cm superior and medial to the anterior superior iliac spine

www.uptodate.com

http://www.uptodate.com/contents/image?imageKey=GAST/76099&topicKey=GAST%2F16203&source=outline_link&search=paracentesis &utdPopup=true

Routi tine ne Optional nal Unusual Cell count and differential Glucose concentration Tuberculosis smear and culture, adenosine deaminase Albumin concentration LDH concentration Cytology Total protein concentration Gram stain Triglyceride concentration Culture in blood culture bottles Amylase concentration Bilirubin concentration

 Is portal hypertension present?  97% accurate

SAAG > 11 g/L  Portal HTN SAAG < 11 g/L  Other causes SAAG = (albumin concentration of serum) - (albumin concentration of ascitic fluid)

The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Runyon BA; Montano AA; Akriviadis EA; Antillon MR; Irving MA; McHutchison Ann Intern Med 1992 Aug 1;117(3):215-20.

SAAG > 1 11 g/L (PORTAL RTAL HT) SAAG < 1 11 g/L Cirrhosis Peritoneal carcinomatosis Alcoholic hepatitis Peritoneal tuberculosis CHF Pancreatitis Massive hepatic metastases Serositis Budd Chiari Syndrome Nephrotic syndrome Congestive heart failure/constrictive pericarditis

SAAG > 11 SAAG < 11

Ascites Protein <25 Ascites Protein >25

• 1. Check serum

and fluid albumin

Ascites Protein >25

• 2. Check Ascites

Protein

Hepatic Sinusoid source Peritoneum source Capillarized sinusoid Normal sinusoid Peritoneal lymph

Cirrhosis Late Budd-Chiari

• 3. Differential

Diagnosis

Cardiac ascites Early Budd-Chiari Veno-occlusive disease Malignancy Tuberculosis

The SAAG does not need to be repeated after the initial measurement.

Note: Exceptions exist: may have mixed features

Adapted from www.gastro.org

 Is ascites infected?

• Greater than 250 PMN = SBP

 If ascites is bloody ( > 50,000 RBC/mm3), correct by subtracting 1 PMN / 250 RBC

 Is ascites bloody?

• 5% of pts w/ cirrhosis - spontaneous or s/p

traumatic tap.

 Non-traumatic  associated with malignancy

• 20% of malignant ascites
• 10% of peritoneal carcinomatosis

• Total protein >10 g/L
• Glucose <2.8 mmol/L
• LDH greater than serum ULN
• Low sensitivity + specificity however.

 Consistent with infection or malignancy?

• Infection and cancer consume glucoselow

 LDH is a larger molecule than glucose, enters

ascitic fluid with difficulty.

• Ascitis/Serum LDH ratio

 ~ 0.4 in cirrhotic ascites  Approaches 1.0 in SBP  >1.0, usually infection or tumor

 Amylase

• Uncomplicated cirrhotic ascites

 About 40 IU/L. The AF/S ratio is about 0.4

• Pancreatic ascites

 About 2000 IU/L. The AF/S ratio is about 6

 Triglycerides — milky fluid.

• Chylous ascites - TG > 200 mg/dL, usually 1000

mg/dL

 Bilirubin — brown ascites.

• Biliary perforation – AF Bili > serum Bili

 Smear – extremely insensitive  Culture – 62-83% when large volumes

cultured

 Cell count – mononuclear cell predominance  Adenosine deaminase –

• Enzyme involved in lymphoid maturation
• Falsely low in pts with both cirrhosis and TB

 “almost 100%” with peritoneal carcinomatosis

have positive cytology

 Malignant ascites from massive hepatic mets,

HCC, lymphoma are usually negative

 Overall sensitivity for detection of

malignancy-related ascites is 58 to 75 %

 pH

pH,

 lactate

te,

 ‘humoral tests of malignancy’ such as

fibronecti ronectin, cholest ester erol. l.

 No clinical data to back up the finding that

upright position is asscociated with reduced GFR and reduced Na excretion and reduced diuretic efficacy

 Bed rest promote muscle atrophy and other

complications and extends hospital stay

 So bed rest not recommended

 Typical UK diet has 150mmol/day- 15%

added salt and 70% is manufactured salt

 Suggestion is no added salt diet and

avoidance of prepared food

 So that patient gets 90mmol/day ( 5.2gm)  Lowers diuretic requirement, faster

resolution of ascites and shorter hospital stay

 Avoid high salt content of fluid and

medicine except in HRS

 No role in uncomplicated ascites  Most hepatologists restrict fluid in ascites associated with

hyponatraemia- but is illogical

 The downside is water restriction causes increase in the

central effective hypovolaemia- more ADH- more water retension and further dilutional hyponatraemia

 So hepatologist including the authors of the BSG guidelines

suggest further plasma expansion to inhibit ADH secretion

 Data emerging supporting use of specific vasopressin 2

receptor antagonists

 To be effective the intake should be less than urine output

rather than arbitrary 1.5L/day

 If the serum sodium concentration does not increase within

the first 24 to 48 hours, the degree of fluid restriction has been insufficient.

 Spironolactone is drug of choice  Aldosterone antagonist acting in distal

tubule to increase natriuresis and conserve potassium

 Initial dose 100mg and increasing up to

400mg

 Lag of 3-5days  Better natriuresis and diuresis than a loop

diuretic

 Antiandrogenic effect- gynaecomazia-

tamoxifen 20mg bd

 Hyperkalaemia frequently limits the use

 Frusemide has low efficacy in cirrhosis  Use only if 400mg of spironolactone fails to

achieve weight loss

 Start at 40mg a day and increasing by 40mg

every 3rd day to max of 160mg

 Watch out for metabolic alkalosis and

electrolyte disturbance

 Weight loss

• Loose 0.5kg a day when no edema
• Loose 1kg a day when edema is

present

 Avoid renal failure  Response rate in up to 90%

patients who do NOT have renal dysfunction

Hepatology 2003; 38: 258-266 Dig Dis 2005; 23:30-38

 Over diuresis is associated with

intravascular volume depletion, leading to renal impairment, hepatic encephalopathy and hyponatraemia

 10% will have refractory ascites  Dietary history to exclude salt ingestion-

24hr urinary Na excretion should be less than recommended intake

 Drug history - NSAID

Na 126-135 and normal creatinine Continue diuretic Do not water restrict Na 121-125 and normal creatinine Continue/? discontinue Na 121-125 and high Creatinine Stop diuretic and give volume expansion Na <120 Stop diuretic

 Give only if renal function is worsening –

creatinine >150 or 120 and rising

 Gelofusion/Haemaccel/ 4.5% albumin –all

have 153mmol of Na per L

 This will worsen salt retention but better to

have ascites than to develop HRS

 Re

Refractory ctory asci cite tes- cannot be mobilised or early recurrence of which ( that is after therapeutic paracentesis) cannot be prevented by medical treatment

 Diuretic

etic resista stant nt asci cite tes- refractory to dietary salt restriction and intensive diuretic treatment ( spironolactone 400mg and frusemide 160mg per day and salt restricted diet of less than 90mmol/day ( 5.2g/day)

 Diuretic

etic intol

• lerant

erant as asci cite tes- refractory to therapy due to the development of diuretic induced complications

 Total paracentesis is associated with

significant haemodynamic changes

 Large volume paracentesis causes marked

reduction of IAP and IVC pressure- decrease in right heart pressure and

 This changes are maximal at 3hrs

 International ascites club recommend if <5L is removed

synthetic plasma expander can be used and as good as albumin ( some hepatologist suggests no albumin/plasma expander if <5L)

 Compared to albumin, artificial plasma expander cause more

activation of Rennin Angiotensin System , causes more hyponatraemia and results in longer hospital stay

 20% albumin should be infused after paracentesis of >5L at

dose of 8g/L of ascites drained ( 100ml of 20% albumin= 20gm, so 3L of ascites fluid removal needs 3x8=24 gm of albumin replacement = 125ml but we tend to round it to 100ml)

 5 percent albumin can be given if dehydration is suspected.

 Use Z technique- puncture site on the skin

does not overlie the puncture site on peritoneum

 Left flank is preferrable to right flank  After drain is out patient lie on opposite site  Colostomy bag if continuous leakage (

some use purse string suture)

 As rapidly as possible- should not be left

• vernight

 No upper limit of 8 litres or maximum time

• f 6 hours has been mentioned in the

guidelines

 Transjugular

Intrahepatic Portosystemic Shunt

 Creates a conduit

from the high pressure portal system to the lower pressure systemic circulation

 Highly effective treatment  Complete resolution in 75% of cases  No effect on survival in one study and reduced on

• thers- compared with therapeutic paracentesis

 HE occurs in 25% of patients , more if >60yrs  May precipitate heart failure as increase cardiac

preload

 TIPSS should be considered for patients who

require frequent paracentesis ( >3 a month)

 It also shown to resolve hepatic hydrothorax in 60-

70%

 MELD was originally developed to predict survival

after TIPSS insertion

 Mortality of 50% within 2yr of diagnosis  Once refractory to medical therapy 50% die

within 6 months

 Time for referral to transplant centre as

paracentesis and TIPSS does not improve long term survival except improving quality of life

Spontaneous Bacterial Peritonitis

 Initiate for PMN≥250/mm3  Antibiotic – follow trust guidelines  Duration of therapy unclear

• 2 weeks suggested if Blood

cultures(+)

• If repeat paracentesis at 48 hours

shows PMN≤250/mm3, then 5-7 days of treatment may be adequate

 40% develop HRS during the course of

illness.

 Human Albumin 1.5gm/Kg o day one and

1 gm/Kg on day three has shown improvement in both morbidity and mortality. Ult ltim imat ate e treatme ment: nt: Liver transplant.

70 % recurrence in 1 yr

 Prophylactic antibiotics should

also be prescribed indefinitely unti til l ascite ites has elimina iminated ted

 Options include:

• Bactrim DS 1 tab po 5 days/week
• Cipro 750mg po q week

1.

Up to Date

2.

Ascites and renal dysfunction in liver disease, Second edition. Edited by Pere Ginès, Vicente Arroyo, Juan Rodés, and Robert W. Schrier. Malden, Mass., Blackwell, 2005.

3.

The serum-ascites albumin gradient is superior to the exudate- transudate concept in the differential diagnosis of ascites. Runyon BA; Montano AA; Akriviadis EA; Antillon MR; Irving MA; McHutchison Ann Intern Med 1992 Aug 1;117(3):215-20.

4.

Becker, G. Malignant ascites: Systematic review and guideline for

• treatment. European Journal of Cancer 42 (2006) 589 - 597

5.

Aslam, N. Malignant ascites; New concepts in pathophysiology, diagnosis, and management. Arch Intern Med. Vol 161. Dec 10/24, 2001. 

Cause Testi ting ng Alcoholic liver disease History, AST / ALT > 2 Chronic hepatitis C Hep C Ab, Viral load Primary biliary cirrhosis Antimitochondrial antibodies Primary sclerosing cholangitis Contrast cholangiography , ANA, Anti smooth muscle Ab, ANCA Autoimmune hepatitis Type 1: ANA, ANCA antismooth muscle Ab Type 2: anti-LKM-1 Chronic hepatitis B Hepatitis B serologies Hemochromatosis Ferritin, genetic testing Wilson’s disease Ceruloplasmin Alpha-1-antitrypsin deficiency Serum AAT Nonalcoholic fatty liver disease Hx of DM or metabolic syndrome

 Occur when weight of

ascites is sufficient to push the flanks

• utwards

 Difficult to

distinguish from

• besity

 Sensitivity-72-93%

• Pooled data 81%

 Specificity-44-70%

• Pooled data 59%

JAMA 1992; 267:2645-48

 Similar to bulging

flanks, although uses percussion

 Typically bowel will

float to the top and ascitic fluid sinks to the bottom

 Sensitiv

itivity ity-80 80-94% 94%

• Most sensitive test
• Pooled data 84%

 Specificity-29-69%

• 69% outlying value
• Pooled data 59%

JAMA 1992; 267:2645-48

 Find the point where

flank dullness occurs

 Mark it  Roll the patient away

from the examiner

 Repeat percussion

and ensure that the point moves to the dependent side

 Sensitivity-60-83%

• Pooled data 77%

 Specificity-56-90%

• Pooled data 72%

JAMA 1992; 267:2645-48

 Medial edges of both

hands down midline

 Tap flank firmly and

feel for an impulse on the other side

 Sensitivity-50-80%

• Pooled data 62%

 Spec

ecifi ificity city-82 82-92% 92%

• Most specific test
• Pooled data 90%

JAMA 1992; 267:2645-48

 Have patient prone 3-5

minutes then rise to crawling

 Place the diaphragm of

the stethoscope over the most dependent area of the abdomen

 Flick a finger until sound

detected

 No longe

nger recommended ended

 Formerly used for high

sensitivity

 Sensitivity-43-55%

• Pooled data 45%

 Specificity-51-83%

• Pooled data 73%

JAMA 1992; 267:2645-48

 Ultrasound is the

most sensitive test for ascites (100mL detection)

• Have to use caution as

small or even moderate ascites may be difficult to tap (even when marked)

• Ensure mark is

appropriate

 Go with patient to U/S (ideal)  If not possible, in order specify location where you want to place your needle

Image from www.gastro.org

 Definition: abnormal accumulation of fluid

in the peritoneal cavity as a consequence of cancer.

 Commonly caused by cancers of:

• Breast, bronchus, ovary, stomach, pancreas, colon

 20% of cases have tumors of unknown

primary

 Survival poor – usually less than 3 months Becker, G. Malignant ascites: Systematic review and guideline for treatment. European Journal of Cancer 42 (2006) 589 - 597

 Obstruction of lymphatics by tumor

• Prevents absorption of fluid and protein

 Alteration in vascular permeability

• Hormonal mechanisms (VEGF, IL2, TNF alpha)

 Decreased circulating blood volume

• Activates RAAS leading to Na retention

Becker, G. Malignant ascites: Systematic review and guideline for treatment. European Journal of Cancer 42 (2006) 589 - 597

Denver Shunt (Similar to LaVeen Shunt)

Contraindications

• Protein > 4.5 g/l (occlusion)
• Loculated ascites
• Coagulopathy
• Advanced renal/cardiac disease
• GI malignancy

Complications

• Infection
• Hematogenous spread of mets
• DIC
• Pulmonary edema
• Pulmonary emboli

 Therapeutic paracentesis

• Removing up to 5L appears safe
• No good data on role of volume expanders

 Diuretics

• Equivocal evidence of efficacy
• May be helpful for portal HTN
• Less/minimally useful when no portal HTN

 Drainage Catheters  Peritoneovenous shunts